ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
What assessment finding is the earliest sign of hypoxia?
Correct Answer: A
Rationale: Restlessness is considered the earliest sign of hypoxia. When the body is not receiving enough oxygen, the brain sends signals to increase the respiratory rate in an attempt to compensate for the lack of oxygen. This increase in respiratory effort can lead to restlessness as the body tries to improve oxygenation levels. Therefore, restlessness is often one of the first signs that a person may be experiencing hypoxia. It is important to recognize this early sign and initiate appropriate interventions to prevent further deterioration in oxygen levels.
Question 2 of 5
The nurse is planning care for a client with a diagnosis of COPD with a high anxiety level that causes SOB. Which action should the nurse take given the client's reaction to anxiety?
Correct Answer: B
Rationale: The correct answer is B) Teach pursed-lip breathing to use when feeling anxious. This option is the most appropriate because pursed-lip breathing helps COPD patients manage their shortness of breath, which can be exacerbated by anxiety. By teaching this technique, the nurse empowers the client to self-manage their symptoms in real-time. Option A) Administer prescribed anti-anxiety medication PRN may provide temporary relief but does not address the underlying issue of coping mechanisms for anxiety and shortness of breath. Option C) Discouraging visitors who may cause anxiety to increase does not promote effective coping strategies for the client. Option D) Teaching proper use of inhalers to control anxiety is incorrect because inhalers are used to manage the physical symptoms of COPD, not anxiety directly. In an educational context, it is crucial for nurses to understand the holistic approach to care for clients with COPD, addressing not only physical symptoms but also psychosocial aspects like anxiety. Teaching clients coping strategies empowers them to better manage their condition, leading to improved outcomes and quality of life.
Question 3 of 5
A client with COPD reports difficulty breathing while lying flat. What intervention should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Encourage the use of a recliner chair. This intervention helps alleviate difficulty breathing while lying flat in a client with COPD by allowing them to sit in a more upright position, which reduces the pressure on the diaphragm and lungs. Option A) Teach diaphragmatic breathing techniques, while beneficial for COPD management, does not directly address the immediate issue of difficulty breathing while lying flat. Option C) Elevate the head of the bed to 30 degrees is a common intervention for clients with respiratory issues, but a recliner chair provides better support and comfort for clients with COPD experiencing difficulty breathing in a lying position. Option D) Administer bronchodilators before bedtime is not directly related to the positional discomfort experienced by the client, and it may not effectively address the immediate issue of difficulty breathing while lying flat. Educationally, understanding the rationale behind choosing a recliner chair for clients with COPD can help nurses provide appropriate care tailored to the individual's needs, promoting optimal comfort and respiratory function. It is essential for nurses to be knowledgeable about positioning interventions to manage respiratory symptoms effectively in clients with COPD.
Question 4 of 5
A client with tuberculosis is prescribed rifampin. What is the most important teaching point for the nurse to emphasize?
Correct Answer: C
Rationale: The correct answer is C) Do not stop the medication even if symptoms improve. This is the most important teaching point for the nurse to emphasize because rifampin is an antibiotic used to treat tuberculosis, which is a serious infectious disease. It is crucial for the client to complete the full course of treatment to ensure that all the TB bacteria are killed and to prevent the development of drug-resistant strains. Option A) Avoid direct sunlight to prevent photosensitivity is incorrect because rifampin does not typically cause photosensitivity. Option B) Expect orange discoloration of urine and tears is a common side effect of rifampin due to its color, but it is not as important as ensuring completion of the medication. Option D) Avoid foods high in potassium is unrelated to rifampin therapy and is not a significant teaching point for this medication. In an educational context, it is essential for nurses to understand the rationale behind medication teaching to provide comprehensive care to their clients. By emphasizing the importance of completing the full course of rifampin therapy, nurses can help ensure treatment success and prevent the spread of tuberculosis. This teaching point highlights the critical role of patient education in promoting adherence to treatment regimens and improving health outcomes.
Question 5 of 5
The nurse is teaching a client with asthma about avoiding triggers. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: The correct answer is B: "I can sleep with my pet as long as I vacuum regularly." This statement indicates a need for further teaching because pet dander is a common trigger for asthma symptoms. Even with regular vacuuming, the pet dander can still be present in the environment and can exacerbate asthma symptoms. It is important for individuals with asthma to avoid exposure to pet dander to help manage their condition effectively. Option A is correct as individuals with asthma should avoid cleaning products with strong odors as these can trigger asthma symptoms. Strong odors can irritate the airways and lead to breathing difficulties for individuals with asthma. Option C is correct as outdoor exercise during high pollen seasons can expose individuals with asthma to allergens that can trigger asthma symptoms. It is recommended for individuals with asthma to exercise indoors or during times when pollen levels are lower. Option D is correct as using air conditioning can help reduce indoor humidity levels, which can create a more comfortable environment for individuals with asthma. High humidity levels can promote the growth of mold and dust mites, which are common asthma triggers. In an educational context, it is important for nurses to provide detailed and accurate information to clients with asthma to help them effectively manage their condition. Teaching about asthma triggers and how to avoid them is crucial in empowering clients to take control of their health and prevent asthma exacerbations.